A Revolution in Dermal Filler Injections

It has been 3 months since we began using blunt cannulas for filler injections. I wish I could forget the needles all together! There is no reason to subject my patients to the risk of bruising or bleeding if a better and safer alternative is available.

The needle-less filler injection is the single most monumental change that has occurred in the field of dermal fillers in several years; it has spread throughout Europe and South America very rapidly since it’s introduction less than 2 years ago. Aesthetic physicians around the world have embraced this chance to make filler injection strikingly less unpleasant and cut the risk of bleeding and bruising to almost negligible!

There seems to be another advantage of using cannulas. If placed properly and in a particular fashion the metabolism of the product could be delayed and the filler may last much longer!

The concept of a no-needle technique is not a new idea; it has been used for fat transfer for quite some time. Yet, the use of cannulas for dermal filler placement is hardly known in this country; even the representatives of filler companies are not familiar with this concept. It is somewhat puzzling since the reps from the same companies in South America or Europe are well versed in this technique and share all necessary information with their physicians. They are instrumental in helping their doctors to attain the necessary skills and equipment; both as a free addition to the purchased fillers.

The main problem is the availability of the cannulas, the blunt “needles” necessary for the injection of fillers.

Since the procedure is quite new, there are very few committed dermal filler cannula manufacturers around the world, however they work closely with the manufacturers of dermal fillers. Their products are available in several sizes and various lengths. These companies have grown exponentially within the last 12 months due to the enormous popularity of this technique and the continuously growing demand.

Overall, the no-needle injection technique is a major step forward in Aesthetic Medicine making filler injections a procedure that is much safer, less traumatic and with negligible downtime. There are reports of a longer duration of these dermal fillers when injected through a cannula.

There are only 4 centers in the US who use cannulas; two of them use this technique for lips only. We are very proud to be one of only two centers in the USA using this technique for total facial aesthetics.

What’s New with Dermal Fillers?

What’s New

Dermal fillers have been in use for several years. All non-permanent fillers have an impressive safety record allowing them to become a prime mode of rejuvenation.

With several dozens of fillers available around the world, we have only 6-7 products approved by FDA. Sadly, even the largest filler manufacturers have only handful of their products on our market while in Europe, South America and Asia several lines of dermal fillers are available.

The majority of fillers around the world are hyaluronic acid products. These are transparent gels of different thickness and different physical characteristics.

The thinnest products are used for very superficial injections in order to maximize skin hydration and provide fresh look. These products may need a touch-up every 2-3 months for the maintenance.

Thicker products provide much longer duration. The thickest hyaluronic acid fillers are used for the volumizing of face and other parts of the body. Their effect may last in certain areas for 2 yrs or more.

The concept of dermal filler has changed dramatically around the world almost 4 years ago; the injections concentrate on volume restoration and areas of enhancement  rather than simplistic filling of the visible lines.

Restoration of the volumes and understanding of light perception will provide an ultimate artistic/aesthetic results.

The most popular hyaluronic acid fillers around the world for the restoration of facial volumes areTeosyal Ultimate, Restylane SQ, and Juvederm Voluma. For non-facial volume restoration the Macrolane (made by the makers of Restylane) has been very successfull for over 2 years. None of the above are available in the US at this time. But, stay tuned. I predict that FDA will approve at least some of them soon since they clearance has nothing to do with their safety.

The hyaluronic acid fillers available on the US market are: Juvaderm Ultra, Juvaderm UltraPlus, Restylane, Perlane, Prevelle and Hydrelle. In practice, the last two are of minimal interest due to their suboptimal characteristics. Even with a minimal choice of available products one may expect excellent aesthetic results and fairly long lasting effect.

Personally, my favorite hyaluronic acid products are Teosyal Ultimate and Juvaderm UltraPlus. Teosyal Ultimate is the newest addition to the extensive line of hyaluronic acid products from a Swiss company Teoxan. Released just few weeks ago it provides almost perfect volume restoration when using in deep injections; its high thickness and great elasticity result in significant resistance to deformation and degradation. Consequently, this filler may last 18 months or more.

I was very impressed  with the ease of Teosyal injection, its smoothness and ability to restore the volume when injected using the no-needle technique. Unfortunately, Teosyal is not yet approved by FDA.

Juvaderm UltraPlus is overall great product for various applications. However, due to it’s small syringe volume and relatively high price, I find it difficult to use this product for larger volume restoration. It is unbeatable for lips and more superficial injections.

Aside of the hyaluronic acid fillers there are very few non-permanent products on the market:Radiesse, Sculptra and collagen fillers. The collagen fillers are of marginal use due to their short lifespan. Sculptra has markedly delayed visible response which may be difficult to monitor and plan ahead although those who use it report great results.

Radiesse remains an excellent filler for volume restoration and deep lines. In addition, at present pricing trends, it remains the most economical/cost effective agent with the largest syringe volume and relatively long lasting effect.

The permanent and semi-permanent synthetic fillers are still available. I do not use them and most likely never will. I would never recommend them to my patients under any circumstances. Once injected they are irretrievable.


The standard injections of dermal fillers can be quite unpleasant along with frequent bruising and bleeding. One can reduce the discomfort of injection by numbing the area with Lidocaine.

Although some use topical anaesthetic, these provide only superficial effect that is of minimal help with deep injections.

Alternatively, the anaesthesia can be achieved by injecting Lidocaine near the nerve supplying the injected area.

Up until recently, my preferred technique for needle injection involved mixing every product with the Lidocaine before every injection. This allows to numb the area during initial stages of injection making it much more comfortable.

But, to provide nearly painless injection, I begun to use a blunt technique that recently has revolutionized the majority of filler injections in many countries.

This technique gives the patient an amazing advantage over the traditional needle injections; it allows a nearly painless and precise injection, eliminates the need for multiple injection entry points and the risk of bleeding or bruising is dramatically reduced.

To summarize, the dermal fillers are here to stay. I expect much more fillers to be approved by FDA within next several months to provide our patients with the best choice of products.

But the most encouraging to our patients is the fact that the times of painful and bruising filler injections may well belong to past.

Meantime I will continue to take every opportunity to use the newest products in Europe before they reach our market.

One remains unchanged: LESS is MORE!

Aesthetics or Aesthetics? Part V


Since more and more medical aesthetic offices open their doors, it becomes exceedingly difficult to choose the best one for your facial aesthetics. There are very few valid criteria one can rely on; on one hand we all hear about the disastrous results of non-qualified injections of fillers and Botox, DIY stories, products coming from suspicious  sources, a habitual dilution of products etc. On the other hand, we see all around us the disturbing results of “aesthetic” procedures coming from the offices of certified and licensed physicians.

So, how to make a decision? How to be sure that all that may be done is all that needs to be done and the results will be natural and enjoyable ?

First, and the crucial step, is a self-education. Define what bothers you the most and start with searching the options to correct it. Never say that everything in your face bothers you; you are setting yourself up for a quite expensive trip.

Read as much as you can about your problem, talk to your friends who are familiar with aesthetic services, identify possible steps in achieving your goal. Try to be prepared as well as you can before making an appointment.

One of the most popular websites is www.realself.com. There, you will find plenty of information just about every procedure that is used in aesthetic medicine and plastic surgery. Although you will read frequently the self-serving comments of aesthetic physicians, this website will give you enough information to ask an informed question.

Remember that not everyone needs laser resurfacing, filler or Botox just because these are available and others do it.

Second, which aesthetic place to choose? Look for an independent review of local aesthetic offices such as comments on City Search or local forum.  Your friends, most likely, will serve as an excellent, if not the best resource. Talk to them about their experience and satisfaction with the results.

Remember, the Aesthetic Medicine is a business and you may expect the traditional selling practices. Ask your friends about these; if they feel pressed, scratch the place off your list.

The most important part in decision making is the choice of a doctor. And here too, your friends will help you by relating their experiences and impressions.

Make always sure that a doctor is on premises full time and actively involved in more invasive procedures. Many “medspas” have a “supervising” physician who is not always present. Avoid these for your safety.

If you are interested in Botox or filler injections ask who does them. If these procedures are not done by a physician but delegated to the staff members you may safely disregard that physician’s credentials and certifications since the results of these procedures dependent only on the skills of the injector. Doctor’s supervision in this situation is completely immaterial in your decision making process.

If an expensive procedure is offered, such as laser resurfacing, body contouring or skin “tightening”, ask if the doctor will be doing these. If not, consider the alternatives.

Many Aesthetic Medicine offices advertise their services emphasizing a particular specialty and certifications of the doctor. If the more invasive procedures are done by that doctor than the place should be on your list; if not, than you may logically dismiss the importance of that doctor’s credentials.

The best you can do is to educate yourself as much as you can. Never be afraid to say no to a proposed treatment plan if you are not sure.

Medical Aesthetics is exciting and incredibly creative part of medicine. It is not, however, a sublime brain surgery and I doubt it will ever be. It is not very difficult to understand the major procedures and their effectiveness. Ask always about the chances of having no visual improvement or pleasing results, especially if the proposed treatment is expensive.

Take your long-term skin care step by step; do not rush with decision regarding expensive procedures. If these are so good they will always be available; if not, than these were of no value  to begin with.

Most of the time there are less expensive alternatives.

Third, seek the initial consultation. It will give you a feel for the practice. Ask questions. Then ask more. Remember, it is your face and your money.

If Botox is considered always ask about number of units you are to receive. I am still amazed how few patients that have been using Botox for years know the dosage they were receiving!

Ask about the concentration of Botox. Botox comes as a powder; it needs to be reconstituted with sterile solution to make it injectable. If too much solution is used, Botox becomes more diluted and may easily diffuse beyond the injected area. With few exceptions this is never desirable.

If you are interested in a dermal filler make sure you clearily understand the recommended volume. One syringe of almost any available filler can go a long way. You can always add more later .

Always ask for Lidocaine to be mixed with your filler unless you are allergic to it. The vast majority of fillers in the US are not pre-mixed with lidocaine; mixing it takes a moment but provides you with much more comfortable experience.

Make sure you understand beforehand the aesthetic reason for filler injection in a given area. The filling of a fold is not a good enough reason; ask what it will accomplish aesthetically other than having a…filler in the fold. The most common injection site are so called naso-labial folds running from your nose toward the corner of your mouth. It happens that in the majority of cases injecting these folds will bring you a negligible aesthetic effect. However, if the same filler is injected in a more strategic place you may have the most spectacular and immediate aesthetic improvement.

The only objective decision any patient can make with the choice of facial aesthetic practitioner is through the experience of other patients and detailed research of what’s available. The most practical approach tells us that f you need an eyelid surgery you want a surgeon who not only specializes in a blepharoplasty but also has the best aesthetic results. That surgeon could be the worse choice for liposuction but if he is great with the eyelids I would definitely vote for him.

If there is a practitioner who is great with fillers and Botox and his patients have the best and consistent aesthetic results I wouldn’t care whether he is also able to interpret ECG, treat successfully psoriasis or is certified in organ transplantation. Why would I?

The most important of all is your gut feeling when talking to the doctor. There is nothing more comforting than the feeling of honesty and concern. You will do much better if you are being led through the smallest steps rather than forced to make a one big jump. Look for someone who does not use difficult to understand medical and technical terminology. This sad practice is still used to intimidate the patient and avoid any further questions. Do not agree to anything until you understand at least the basics of the proposed treatment.

Does it matter whether the Aesthetic Medicine physician who does the facial aesthetics is a Plastic Surgeon? Yes, if a surgical intervention is considered. One of my favorite Plastic Surgeon whose work we all see everyday on the screens has replaced a significant percentage of rhinoplasties – his hallmark- with non-surgical reshaping on the nose using noninvasive and creative combination of filler and Botox. So, even if a surgery is contemplated, ask for the alternatives and if these exist ask your doctor to help you decide.

Always look for a consistent and, above all, aesthetic outcome and the long term results rather than  for a number of certifications on the wall.

Overall, I agree with that French Plastic Surgeon I described in Part I. Those who create an assembly line of grotesque distortions should not be allowed to perform these procedures and the rest should be qualified based on the outcomes.

Of course, it will never happen that an aesthetic physician will have to be judged based on his/her aesthetic results. It is a shame since if the Aesthetic Medicine is truly a part of medicine, the results should be scrutinized and those with poor outcomes “reformed”.

The future, however, appears to be bright. There is a growing number of patients that begin to recognize the faults of the “old school” of aesthetics and overwhelmingly opt for the aesthetic results with less fillers, smaller breasts, no permanent implants and controlled effects of non-industrial doses of Botox.

Personally, I encourage all to look at the magazines, observe their friends, identify not only the obvious, man-made malformations but to attempt to recognize anything that is “non-aesthetic. These exercises fortify the awareness and make patients more prepared for their decisions in aesthetic treatments.

Aesthetics or Aesthetics? Part IV

The lack of artistic and aesthetic approach is overwhelming even among the “experts” as we have seen in the Part I. The results are often the substitutions of quality by quantity in the fashion that renders, at the best a caricature and, at the worst, a visual monstrosity. Take any celebrity with obvious reconstructive failure. I doubt they sought aesthetic expertise in a cheap motel room with an unknown “non-expert”. Although I can not prove it, I bet that most of them were “beautified” by the board certified specialists or luminaries of the local aesthetic markets.


Are these visual “enhancements” results of complications of the procedure or purposeful distortion? Or, let’s be frank, a simple lack of a necessary talent, therefore, lack of the artistic qualifications?

 I don’t buy a common excuse of some aesthetic physicians that they simply accommodate patient’s desires. One would have to assume that some patients want to have the fish lips, frozen face, atrophic nose, protruding cheeks or uneven eyebrows. By this assumption, the aesthetic failure is being unfairly shifted to the patients. Philosophically and ethically this is not acceptable. 

 In rare cases when unaware patient may actually ask for enhancement that is likely to bring the non-aesthetic results, the role of a physician should prompt him/her to educate this patient; his ethics should not permit him to oblige, no matter how high the monetary reward could be. Anything less than that, in my opinion, would be below an ethical conduct.

Would any conscious general surgeon agreed to shape the incision line for any common surgery in a zig-zag pattern extending through chest and right shoulder just to accommodate patient’s fascination with that particular shape? Would we call that surgeon an accommodating doctor?

 But what if a doctor is unable to apply the basics of artistic interpretation and visualize the final effect?  The “right brain” dominance characteristic of creativity is not our choice; we are either born with it or with “left brain” in charge. It’s a choice of nature as far as we know. We all are the most wonderful individuals with our own originality and talents, including ability to recognize our little faults. But the premium non nocere – first, do no harm- should always lead in medical practice.

Have you ever wonder why aesthetic physicians do not perform tattoos yet usurp an expertise in their removal? The tattoo equipment is not any more, or less, complicated to operate than the majority of modern machines used in aesthetics; it penetrates the skin frequently to the levels beyond the depths of many common lasers procedures; the risks are operator dependent as in laser treatment. Moreover, the results of tattoo creation are more permanent leaving operator with much less room for mistakes than any laser skin procedure.

Whatever our opinion of tattoos is, to make them requires certain degree of talent, understanding of the art form, proportions, artistically difficult representation of three dimensional features in two plane reality and ability to predict the outcome. The majority of tattoo artists, if not all,possess these abilities. Very few aesthetic practitioners, regardless of their specialty or certifications, would be qualified to make a tattoo not because of the technical difficulties but because of a minimal right brain creativity.

So, who is qualified to perform the non-surgical aesthetic treatments, inject fillers and Botox or perform aesthetic laser procedures? This is only partially answered by inconsistent state laws. In general, these can be performed by the physicians, nurses or physician assistants holding a valid state license. However, the ability to understand and interpret the perception process, to visualize the outcome before procedure is completed and to implement creative talents are not required by any laws or certifications.

There is much more to facial aesthetics than a simple legal qualification. Unfortunately, these are not observed or enforced in our money driven Medical Aesthetic reality. And if not for the more and more aware patients, there would never be a drive to improve the outcome of facial aesthetics; not from the practitioners, not from the industry.

Aesthetics or Aesthetics? Part III

Mistakes in comprehension of artistic structure are easily made when an unaware practitioner judges his task within very narrow limits rather than taking into account the overall structure. The local situation may suggest one concept but the total context may demand another. In facial aesthetics the whole is almost always greater than the sum of its parts. The incapacity to grasp a pattern as a whole is a clinical condition called visual agnosisThe above applies most visibly in facial reconstruction from facelift through enhancements with dermal fillers to the effect of botulinum toxin. All through the process of  reconstruction, the able practitioner must bear in mind the structural skeleton he/she is shaping while at the same time must pay attention to the quite different contours, surfaces and volumes that are actually being made. The guiding image in the artist’s mind is not so much a faithful preview of what the completed work will look like, but mainly the structural skeleton, the configuration of visual forces that determines the character of the visual object.


The form of created object is a visible image and shape of the content.  Art itself aims at a graceful but deceitful illusion of reality, and any deviation from reality must be  either avoided, excused  or justified.  If the final outcome fails to fit this concept it is a result of one of the following:

–  the practitioner lacks the skill to accomplish the task,

–  the practitioner depicts what he knows rather than what he sees,

–  the practitioner blindly adopts the pictorial conventions of his peers,

–  the practitioner applies the correct principle from an abnormal point of view,

–  the practitioner perceives wrongly because of defects in his eyes or central nervous system defined as visual agnosis,

–  the practitioner deliberately violates the rules of correct representation

The inability to understand the perception, with results similar to naive realism style, assumes that there is no difference between the object and it’s image perceived by the mind so the mind sees the object itself. This simplified but erroneous concept is then introduced into creative process reducing it to a stiff template… a standardized plastic surgery based on physical data, measurements and ratios. This approach can not bring aesthetic results.

As a practical example a recent report revealed that 21% of all rhinoplasties (nose jobs) are…corrections of badly done nose jobs!

21%! 1 in 5 patients had their noses done by someone with defective aesthetic perception or poor skills. Would 21% failure be tolerated in any non-cosmetic surgical procedures, eg. open heart surgery, gallbladder surgery or removal of tonsils?  Similar results were recently reported on breast augmentation results. No need for comments here.

The major trend in most aesthetic procedures is a drive toward the least invasive procedures. More invasive procedures remain, and should remain, within surgical specialty. These require full surgical training and results are frequently more permanent.

Sadly, the completion of Plastic Surgery training does not depend on any comprehensive understanding of artistic/aesthetic perception or familiarity with the art form. The training should, at least, make them aware of any potential deficiencies that might be a source of aesthetic mistakes in real practice.

If Plastic Surgery training has minimal exposure to true aesthetics, other specialties have no exposure at all. From that point of view, in general terms, only Plastic Surgery training brings licensed physician a bit closer to the artistic understanding necessary in Aesthetic Medicine.

There are exceptions to this rule. I know personally a Plastic Surgeon who is an artist…a virtuoso of his trade. He works on many international celebrities without leaving a trace of enhancements and  remaining conservative in his approach.  Moreover, he is constantly perfecting a non-surgical and minimally invasive approach to many aesthetic problems creating masterpieces with various fillers and botulinum toxin.

I’m sure there are more Plastic Surgeons like him. I hope.

The non-invasive and minimally invasive procedures such as injectable dermal fillers, botulinum toxin, laser and light procedures are relatively uncomplicated in nature but require, like all human tasks, certain amount of knowledge, training and practice. They MUST, contain the same key ingredient: the aesthetic understanding of the art form. Without it, the optimal results are simply impossible regardless of the medical specialty, training, certifications or marketing claims. It is simple as that.

Sadly, the training courses teach a bare minimum necessary to…obtain a certificate allowing it’s holders to practice the “aesthetic medicine”.

Aesthetics or Aesthetics? Part II

The LESS IS MORE philosophy is of particular importance in Aesthetic Medicine. It is not a concept, it is the sine qua non, a requirement of this specialty; it is a basic prerequisite without which it becomes an assembly line of non-aesthetic monstrositiesI can’t help but to feel sorry for those who unknowingly lost the chance for natural look  and angry at those who were allowed to introduce pure kitsch to human physiognomy by distorting natural beauty and, in effect, insulting the name of Aesthetic Medicine. Overwhelming preoccupation with the lifestyles of “famous” may force some to take direct cues from “transformed” celebrities and attempt to imitate their unnatural features. They frequently assume, unfortunately, that by acquiring star-like appearance, mostly non-aesthetic, one will enhance his or her chances in life. Whatever those chances could be.


We know some of them from media, some are our acquaintances, some are less known but their man-made features are on display in local magazines. We like some of them, admire amazing talents or generosity of others, yet physically, most of us would agree, they represent a template of distorted perception and bad taste of those who manufactured their features without any indication of artistic sense or talent.

Very few patients understand that one can obtain the most wonderful and natural results with minimal use of aesthetic tools. You can have enhanced lips with natural curvatures and proportions using only a fraction of “traditional” volume of the filler.  You can, most of the time, enjoy the most dramatic immediate facial rejuvenation by applying small to moderate volume of dermal filler into non-standard area rather than having it injected in place of no aesthetic importance just because it has been traditionally done. The idea of filling lines is in most part an outdated concept that brings overall a negligible aesthetic effect.

All too often the filler is injected just because…it can be injected.

The same goes for botulinum toxin. Botox is a great sculpting tool that, if used correctly, may provide a long lasting rejuvenating effect. There is absolutely no justification of using so called “recommended doses”; one can enjoy the most pleasing long term results with much smaller doses, still maintaining the ability to retain facial expressions.

Any visual object tends to be seen by us in such a way that the resulting image is as simple as the given condition permit. Our perception gives decisive priority to the simplest patterns we understand and know from the experience. The principle of parsimony demands that when several possibilities fit the facts, the simplest one should be accepted.

The aesthetic practitioner must not go beyond what is needed for his purpose and to achieve optimal results must follow the omnipotent example of nature which, in Newton’ words :“(nature)…does nothing in vain, and more is in vain when less will serve; for Nature is pleased with simplicity, and affects not the pomp of superfluous causes “.

Aesthetics or Aesthetics?

The time has come to look at Aesthetic Medicine from a different point of view.

Let’s discuss the meaning of aesthetics, what has become of it, what it should be and what it could be. I begin with my views on facial aesthetics since this is the key element of the most common misconceptions.

Later in this series of comments, I will try address the endless and ever-changing list of aesthetic procedures, particularly those with claims that do not meet promised results.


Aesthetic Medicine in the US is beginning to transform. It is a painfully slow process that is, to no surprise, not very enthusiastically welcome by some.

Thankfully, the strong winds of change come from the most important source – the patients!

To me it is a clear signal that the “old school” of facial aesthetics is on the way out; permanently, I hope.  If this is true, it will allow us to join the rest of the world of aesthetics, a world that has been light years ahead of us in using medical aesthetic procedures responsibly.

   The issue of monumental importance in Aesthetic Medicine is the perception, understanding and implementation of true aesthetics – an art form that governs any artistic creation. I am not unique in observing, that too many facial aesthetic procedures have been unsuccessful …they are aesthetic failures. I stress the word “aesthetic” since this is the main ingredient that makes the final result of ANY artistic creation, a great success or miserable failure.

The word “aesthetic” means, in general, the art; the nature of art, it’s philosophy, theory and practice. In contains both, the strict rules and their liberal applications as we hear in music and see in visual arts. Tracing these elements from ancient times until present, all original and revolutionary styles that were breakthroughs of their times, share the basics of the art form. The same must be expected from Aesthetic Medicine if we insist on using this name.

  Aesthetic Medicine has its roots in antiquity with a simple human desire to maintain and improve ones appearance. It evolved into Plastic Surgery which has become almost synonymous with the most sophisticated methods of aesthetic improvements.

   Organized Aesthetic Medicine was born in early 80’s in France and quickly spread over Europe, South and North America and Asia. In the last decade it expanded to contain various aspects of health maintenance, overall wellness, prevention of illness and correction of the aging process withenhancement of features and improvement of visible deficiencies.

   Unfortunately, the “enhancement” and “improvement” have spiraled out of control replacing natural beauty with an amateur concept of over-improvement that resulted in antithesis of aesthetics. The abundant examples are all around us: oversized breasts, shapeless and disproportionate lips, protruding cheeks, pencil – shaped noses with upturned, “pinched” tips or a “shrink-wrapped” immobile foreheads with hyper-arched eyebrows.

  It is impossible to say what or who triggered this sub-culture that lingers on like a nightmare. What isknown, is that the rest of the world has followed more difficult trends, shifting their aesthetic forces into natural and artistic enhancements.

  The need for aesthetic services is constantly growing,  reflecting ones natural desire to look as good as possible. Unfortunately, the prevailing trends of facial aesthetics are being defined too frequently by those who have marginal understanding of true aesthetics.

    The physical ability to hold a pencil, brush, chisel, syringe, or laser hand-piece is a minor accomplishment in the scheme of aesthetic creation. However, the very next step, the ability to understand and properly assess the spatial relationships of target area, is what opens…….or shuts the door to the successful project.

  An “Artistic sense” is almost impossible to learn in full….. it is either a part of our perceptive process or not. If it is, the work is inspired and the job is well done….if it is not, one should think of it as notnecessarily a fault of the aesthetic practitioner per se  but  his/her failure to recognize it.

    But what if the practitioner doesn’t want to admit that his/her left brain dominates thus giving the aesthetic doctor all the gifts of scientific brilliancy but making him a poor artist?

   Nothing could better illustrate the point than an event that I witnessed during the 6th Anti-Aging Medicine World Congress in Paris in 2008.  This grand annual event is attended mostly by physicians from countries in Europe, South America and Asia, countries that have been well ahead in implementation of true aesthetics.

   As a part of the Congress, there are live presentations of the newest concepts, from laser procedures to implants and injection techniques.

One of the workshops, a non-surgical cheek augmentation with dermal fillers turned out, unexpectedly, to be one of the most educational and memorable presentations of the Congress.

The injector was a guest expert from the East Coast city in the US; the patient – model, a Frenchman in his early 40’s.

 After a brief introduction the expert began injecting the right cheek of the model.

 Two syringes later, before proceeding to left side, the presenter asked the audience for any questions regarding the injection technique.

  To his surprise several eager hands shot up into the air and the floor was given to an older gentleman, a French plastic surgeon. In his heavy accent, he asked the expert: “Doctor, could you please ask your model to smile?” The request was translated and the patient obliged with a suspicious , almost clownish smile.

  The audience gasped, some laughed, some murmured and the rest contemplated results in silence. The model smiled no more.

   The author of the question continued…:  “This is an unacceptable result for many of us; it’s unnatural, with disregard to proportions and any artistic or aesthetic values. I am sad to say but you would be banned from injecting this way in many countries”.

It was a tense moment to say the least, an embarrassing and humbling  moment for the patient AND the physician. It brought to realization the enormous divide of artistic perception between us here in the US and the rest of the world practicing Medical Aesthetics.

The event was suddenly amplified by the motto of the Congress:

                                                “LESS is MORE”.

CRYOLIPOLYSIS – a breakthrough in non-invasive fat removal

Cryolipolysis is a non-invasive procedure that involves freezing the fat cells to trigger the process of lipolysis (the breakdown of fat) without damage to other tissue types .

The device made by Zeltiq uses a plate-like non-invasive applicator that is placed directly on the treatment area and cooled to near-freezing temperatures resulting in the breakdown of body fat. The fat cells begin a process of natural cell death and removal. The irreversibly damaged fat cells in the treated area are gradually eliminated through the body’s normal metabolism process.  The result is a flattening of fat bulges that is visible in patients over three to four months.

Cryolipolysis penetrates deepest in thick fat areas, tapering to less effect in leaner areas allowing for natural body sculpting.

Cryolipolysis was Invented by world-renowned scientists from Harvard Medical School and the Wellman Center for Photomedicine at Massachusetts General Hospital, Boston, Massachusetts. It is a breakthrough technology that is based on the natural biologic vulnerability of fat cells to the effects of cold via controlled energy extraction.

It appears to be  the next generation of fat reduction procedures reducing the need to pursue extensive liposuction or laser assisted lipolysis (SmartLipo, SlimLipo etc.)

Findings from the first multi-center study of non-invasive cryolipolysis in humans were presented at the 29th Annual Conference of the American Society for Laser Medicine and Surgery (ASLMS) in National Harbor, Maryland.

The data have confirmed that cryolipolysis treatment is safe and provides a significant benefit of fat volume reductions when performed in a routine clinical setting.  The prospective clinical study also corroborated earlier animal research showing that precisely controlled cooling via a hand-held applicator attached to a sophisticated medical device causes a gradual reduction of targeted fat cells through a naturally induced cell death without harming surrounding tissues. This mechanism of action is fundamentally different from ultrasound or heat-based approaches that create acute injury and eliminate fat cells through traumatic cell death.

This is the first controlled study to demonstrate that cryolipolysis for fat layer reduction in men and women is well-tolerated procedure and produces a visible contour change in all 100% subjects. Unlike traditional surgical procedures to remove fat, cryolipolysis is performed without needles, incisions, anesthesia or pain medication, plus there is no recovery time.

Clinical Study:

Thirty-two male and female subjects age 18 and older with clearly visible fat on the flank (love handle) or back considered appropriate for treatment with cryolipolysis participated in a multi-center, prospective, non-randomized study.

Based on results from these evaluations, researchers confirmed that cryolipolysis resulted in a visible contour change and, specifically, the ultrasound measurements demonstrated a fat layer reduction in 100 percent of subjects with an average reduction of 22.4 percent at four months after treatment.  The subjects with modest fat bulges had the best cosmetic results from the procedure, and no device-related adverse events were reported by any of the subjects.

The study showed that cryolipolysis produces gradual reductions in fat layer after only one treatment while avoiding damage to the surrounding tissues.


Several days after the procedure, the cooled fat cells begin a process called “apoptosis” and begin to shrink. These damaged fat cells are slowly digested over several months by our bodies and removed through the liver. The procedure is highly effective and is producing consistent results for local areas of fat like the love-handles, back and belly. The larger areas of fat may require more invasive treatments.

The best candidate for cryolipolysis is someone who is in relatively good shape, but has modest areas of fat bulges that they’d like removed. It’s not an alternative to healthy diet or lifestyle.

Possible Side Effects:

Side effects are usually mild and related to the cold of the device which subside within 10 minutes. Skin may be red for several minutes to several hours. Other side effects may include temporary bruising, tingling, tenderness, temporary dulling of sensation or cramping.

In summary, the cryolipolysis seems to be almost perfect and truly non-invasive procedure for consistent fat removal without any downtime or significant side effects.

There are several features that are very attractive yet for me the most important are the reliability of 100% effectiveness and the top scientific name standing behind the product.

Cryolipolysis was approved for use in the European Community and Canada; it is expected to receive FDA approval very soon. As soon as the device is available it will be our priority to provide this treatment modality to our patients.

Stay tuned for the updates….



In October 2009 issue of “Plastic and Reconstructive Surgery Journal I found the following article:

Less pain during injections for wrinkle-fighting facial fillers.

Less swelling afterwards.

Less time in the office waiting for anesthesia to take effect.

These are other benefits of a new injection technique that UT Southwestern Medical Center plastic surgeons are helping pioneer and are outlined in the October issue of Plastic and Reconstructive Surgery.  The procedure combines lidocaine with injections of facial fillers to instantly minimize the pain and allows plastic surgeons to begin the injection procedures without waiting for traditional anesthesia to take effect…

And so on…

The addition of anesthetics to dermal fillers is nothing new in the world.  In Europe, South America and Asia this method has been used for years and years.  Not anymore though, because the major filler companies pre-mix their fillers with Lidocaine which are available in variety of products.

I have been using this technique since our doors opened 2 years ago.  I was formally trained with advanced Botox injections in 2007 by an instructor who had been pre-mixing fillers with Lidocaine for at least a year.

Am I misunderstanding the word “pioneer”?

Collagen & Elastin

When you buy these creams (Collagen & Elastin) you are throwing away money – it is a daily fix, not a lasting one. You put the cream on, it makes the wrinkles puff out and seem smaller, but by the end of the day the effect is gone.

Collage fibers are not absorbable in any significant manner. These creams do nothing more for the skin, in the long run, than a regular and inexpensive moisturizer.